Exercise

Research has demonstrated that individuals diagnosed with severe mental illness, including schizophrenia and bipolar disorder, typically have a reduced quality of life and poorer physical health compared to the general population. Recent evidence suggests that individuals with psychosis have a greater risk of developing cardiovascular disease and metabolic disorders such as Type 2 diabetes. Factors including sedentary lifestyle, poor diet composition, higher rates of obesity and smoking have been shown to increase the likelihood of physical health problems. However, all of these risk factors can be treated or changed to help reduce the risk of developing cardiovascular disease.

Some risk factors including tobacco exposure, harmful use of alcohol or drugs, obesity, unhealthy diets, high blood pressure, high cholesterol and physical inactivity can be changed through a healthy lifestyle. Just because you have a risk factor it does not mean that you will go on to develop a disease or metabolic disorder, rather it indicates that you are more likely to develop a disease unless you take action to reduce your risk.

The following links provide information on how to assess your physical health risk according to your body mass index (BMI) and waist circumference, things to consider before getting started on an exercise programme, and a guide to the different types of exercise that are most effective for individuals with psychosis.

Assessing your physical health

In addition to blood tests taken by your doctor, measurements such as body mass index (BMI) and waist circumference, provide valuable information to assess your physical health.

Both of these measurements assess if your weight is putting you at an increased risk for developing cardiovascular disease and/or metabolic disorders.

What is Body Mass Index (BMI)?

BMI is calculated by dividing a person’s weight in kilograms by his or her height in square metres (kg.m2). BMI is not used to determine body fat percentage; rather it is a good indicator of your risk for chronic illnesses such as heart disease, obesity, and Type 2 diabetes.

As BMI does not directly assess body composition (fat vs. fat-free tissue), it may be less accurate in assessing healthy weight ranges in specific population groups. BMI has been shown to be less accurate in individuals who:

  • Perform vigorous resistance training such as bodybuilders, weightlifters, and elite athletes
  • Are from certain ethnic groups including South Asian, Chinese and Japanese, Aboriginals, and Pacific Islander populations
  • Are elderly, pregnant, extremely obese or have a physical disability, eating disorder or under the age of 18.

To calculate your BMI, you need to measure your height and weight. For more information on how to calculate and better understand your BMI, speak to your doctor or visit the NHS Choices website ‘What’s your BMI?’ on the link below:

Understanding your BMI results

Using Table 1 below, compare your BMI results to determine your classification. Compared to white Europeans, Asian populations tend to have a higher percentage of body fat at a given BMI; this increases their risk for chronic illness, such as heart disease and Type 2 diabetes.

Table 1. Body Mass Index threshold

White European PopulationsAsian PopulationsDescription
Less than 18.5 kg/m2Less than 18.5 kg/m2Underweight
18.5-24.9 kg/m218.5-23 kg/m2Increasing but acceptable risk
25-29.9 kg/m223-27.5 kg/m2Increased risk
30 kg/m2 or higher27.5 kg/m2 or higherHigh risk

Adapted from the National Institute for Health and Care Excellence (2013)

Why measure Waist Circumference?

Health risk increases with an increase in fat stored near your major organs. If when you put on weight, you store fat around your mid-section (apple-shaped) as opposed to around your hips (pear-shaped), then you have a higher risk of developing physical health problems. Body fat distribution, specifically where you store fat, is an important determinant of whether you will be at increased risk for cardiovascular disease and/or metabolic disorders. In fact, waist circumference alone provides an independent prediction of risk for cardiovascular disease above that of BMI. However used in combination with BMI, particularly for individuals with a BMI > 35.0 kg.m2,it can provide a clearer determination of your risk for cardiovascular disease.

Table 2. Waist circumference thresholds

Increased RiskHigh Risk
Males> 94 cm (37 in)> 102 cm (40 in)
Females> 80 cm (31.5 in)> 88 cm (34.5 in)

To measure your waist circumference:

  • Wrap a flexible tape measure around your waist midway between the bottom of your ribs and the top of your thighs
  • Breathe out naturally
  • Then record the measurement and compare to the chart above.

For more information on understanding the importance of waist circumference, speak to your doctor or visit the NHS website, ‘Why is my waist size important?’

Starting an exercise programme

Adherence to exercise programmes and dietary advice is a key factor for long-term success if you are trying to achieve weight loss. Physical activity and regular exercise has been shown to have significant physical and mental health benefits in individuals with psychosis.

Benefits include:

  • Reduce risk of weight gain
  • Reduce risk for cardiovascular diseases and metabolic disorders
  • Improve mental function
  • Improve mood and self-esteem
  • Improve sleep quality

Research has demonstrated that activities such as self-monitoring, goal setting and social support are effective strategies to assist you in changing dietary and physical activity behaviour.

Click here for a complete list of the physical, mental and social benefits of exercise:

Self-monitoring

Self-monitoring is when you record the different types of physical activities, including details such as the type of activity, exercise intensity, exercise duration (total number of minutes) and calories expended. You may also want to keep track of sedentary behaviours, such as how much time you spend sitting down during the day, time spent watching television or working on the computer.

Wearable technology, such as pedometers and activity trackers (e.g. devices such as Fitbit trackers or Apple Health), have been shown to be effective at increasing physical activity and exercise adherence.

Goal Setting

Setting behavioural goals help you focus on making realistic changes that will make a difference to your lifestyle and will be personal to you. This means you are more likely to achieve them. When setting your goals, make sure they are S.M.A.R.T goals. S.M.A.R.T stands for specific, measurable, attainable, realistic and time-bound (or timely). Below are examples of how to set a S.M.A.R.T. goal.

Specific: set goals that target specific behaviours.

‘I will start an exercise programme’

‘I will reduce the amount of time watching television’

‘I will increase my water intake’

Measurable: Making your goal measurable means adding a number.

‘I will exercise three times per week and for 20-30 minutes each session’

‘I will only watch television 2 hours per night and avoid watching any screens (e.g. computer, mobile, television) 1 day per week’

‘I will drink one additional glass of water every week to increase my daily water intake’

Achievable: Before you start, you need to know what you are trying to achieve. Find out what type and how much exercise is right for you. If you are trying to lose weight, then set a weight goal that is appropriate for you and your body. Research suggests that a 5-10% weight loss is achievable for most people. However, if you are currently taking an obesogenic medication, such as Clozapine or Olanzapine, than weight maintenance may be an appropriate target for you.

Realistic: It is important that you set goals that are important for where you are in your life right now. For example, if you are not concerned about weight loss or this is not the right time for you to focus on weight loss, choose a different goal like increasing physical activity or decreasing stress levels as a way to motivate you.

Time-bound: Set an end-point. Each goal should have a specific time point for completion allowing you to determine if your goal has been achieved. Setting a deadline will also increase the likelihood of you achieving your goal.

How much exercise is right for me?

The American College of Sports Medicine (2014) recommends the following cardiovascular exercise prescription:

  • Aim to perform exercise at least 4 days per week
  • Aim to exercise for a duration of 20-30 minutes each session at a moderate intensity
  • Engage in a wide range of exercises such as walking, cycling and swimming
  • Total exercise session, including warm-up and cool-down, should last approximately 30-45 minutes.

If you are new to exercise, start slowly with just 2 days a week and build up to 4 days over a period of a few weeks. Slowly begin to increase exercise duration by 5-10 minutes every 2 weeks for the first 6 weeks up to a maximum of 30 minutes per exercise session.

For more information and ideas on how to get more active, check out Change for Life, by clicking the link below:

Understanding exercise intensity

Exercise intensity describes how hard you are working during exercise; this is reflected in your heart rate, breathing, temperature, perspiration and the tiredness of your muscles. Exercising at the correct intensity will help you get the most of out of your exercise sessions. If you are a beginner to exercise, it is recommended that you perform aerobic exercise at a light’ to ‘moderate’ intensity with the aim to gradually increase your exercise session to ‘moderate’ intensity.

How to measure exercise intensity

There are varying ways to measure exercise intensity. One way to determine exercise intensity is to assess how you hard you feel you are working using the ‘Talk Test’.

Moderate intensity aerobic exercise is when you are working hard enough to raise your heart rate and break into a sweat. You are working at a moderate intensity if ‘you are just able to respond to conversation’ – this means that you are working at the right intensity.

Vigorous intensity aerobic exercise is where you’re breathing hard and fast and your heart rate has increased significantly. If you’re working at this level, you won’t be able to say more than a few words without pausing for a breath. When starting an exercise programme, this intensity is not recommended for you.

Exercise IntensityPercentage of Maximal Heart RateThe Talk Test
Very light< 50%Talk effortlessly
Light50-64%Talk effortlessly
Moderate64-77%Talk, not sing
Vigorous (Hard)77-94%Talk only a few words
Maximal100%Unable to talk

For more information on moderate and vigorous exercise, speak to your doctor or visit the NHS Choices website: ‘What is moderate and vigorous exercise?’ by clicking the link below:

»
WHAT IS MODERATE AND VIGOROUS EXERCISE? NHS CHOICES

You can also measure your heart rate to determine your exercise intensity. Your heart rate will increase in relation to the intensity of your exercise (i.e. as exercise gets harder your heart rate will increase). You can measure heart rate using your pulse, a heart rate monitor or using the heart rate function available on some exercise equipment.

The American College of Sports Medicine (2014) recommends the following percentages to determine the appropriate heart rate range depending on the intensity of exercise.

»
TRAINING HEART RATE EXERCISE CALCULATOR

Choosing exercise that is right for you!

Different types of exercise

Aerobic exercise, also known as cardiovascular exercise, is activity that increases the body’s demand for oxygen resulting in an increase in heart rate and breathing.

  • Good examples of aerobic exercise include, walking, jogging, cycling, swimming and rowing
  • Benefits of aerobic exercise include improved heart, lung and metabolic function, maintain body weight and body fat, reduction in depression and anxiety, decrease in psychotic symptoms, improved cognition and an improved ability in learning and long term memory.

Resistance training, also known as weight training, is an activity that requires repeated voluntary muscle contractions against a resistance greater than those normally encountered in activities of daily living.

  • Examples of resistance training include using free weights, weight machines, medicine balls, resistance bands or working against your own body weight (i.e. push-ups or pull-ups).
  • Physical benefits of resistance training include improved muscular strength and tone, pain management, improved mobility, balance and posture and enhanced performance of daily tasks.
  • Psychological benefits include improved sense of well-being, increased self-esteem, body image and mood.

Alternative forms of exercise including activities such as Yoga, Tai Chi and Pilates have been shown to help alleviate stress, increase mobility and balance, and improve quality of life. Although these exercises work in different ways, they are all low-impact exercises that are appropriate for all fitness levels. Yoga and Tai Chi focus on meditative and relaxation techniques that help achieve a relaxation response that counteracts the negative effects of stress.

Click here to find a leisure centre or activities provided in your area:

Walking for Health

Regular walking has been shown to reduce the risk of chronic disease including heart disease, type 2 diabetes, stroke and some cancers. The only equipment you need is a good pair of walking shoes that are comfortable, do not cause blisters and provide adequate support. It is recommended that you wear loose fitting clothing, preferably a few thin layers that you can remove as you begin to warm up during the walk.

It is important to stay hydrated, so be sure to drink plenty of water before and after the walk. For longer walks, you may want to bring a water bottle with you.

A great way to calculate your walking is to use a pedometer or activity tracker. A pedometer is a small device you attach at the waist band that records the number of steps per day. The recommended guideline is to achieve 10,000 steps per day.

Click here for more information:

»
10,000 STEPS CHALLENGE

To find a Walking for Health scheme in your area, click here:

»
Walking for Health scheme in your area

If you are looking for a more challenging adventure, click here to learn about charity walks, marathons and cycling events in your area:

»
CHALLENGING ADVENTURES

Resistance Training

Performing resistance training exercises at least two times a week has shown to improve both mental and physical health. For example, research has shown that resistance training may lead to a decrease in depression and anxiety symptoms, an improvement in the brains processing ability, a reduction in chronic fatigue, and improved sleep quality and self-esteem (person’s opinion about him/herself).

A variety of equipment can be used to perform resistance training exercises such as free weights, weight machines, medicine balls, resistance bands or working against your own body weight (i.e. push-ups or pull-ups). However, if you are beginner to exercise, it is recommended that you perform these exercises as part of a circuit training programme or use weight machines. Choose exercises that use multiple joints, such as a squat or chest press, as they require more than one muscle group which will maximise the effectiveness of your workout.

Aim to exercise each major muscle group 2 days per week. The major muscle groups include the: chest, back, deltoids (shoulders), biceps (front of the upper arm), triceps (back of the upper arm), quadriceps (front of upper thigh), hamstrings (back of the upper thigh), abdomen, lower back and calves.

Each exercise should be performed using a combination of sets (number of times that you will perform that exercise) and repetitions (number of times to lift the weight). The American College of Sports Medicine (ACSM) recommends the following exercise prescription for resistance training:

  • Train each major muscle group 2 days per week
  • Begin with one set of 8-12 repetitions of each exercise (50-70% 1 repetition maximum); gradually increase to two sets
  • Allow one to two minutes of rest between sets; allow more than three minutes for heavier weights
  • Allow 48 hours between resistance training sessions
»
STARTING A RESISTANCE TRAINING PROGRAM
»
TIPS ON STRENGTH TRAINING AND SAMPLE HOME WORKOUT PROGRAMS

Designing your own workout session

There are three main parts to any exercise session: warm-up, conditioning phase (either cardiovascular or resistance training) and cool-down. You may wish to do the cardiovascular and resistance training on the same day or separate days.

Warm-up: this phase should consist of 5-10 minutes of light to moderate intensity dynamic exercise such as walking, cycling, cross-trainer, etc. This phase is designed to increase the temperature of the muscles and prepare the body for the demands of the conditioning phase.

Conditioning phase: this phase should consist of 20-30 minutes of cardiovascular or resistance training or a combination of both. Exercise should be performed at a moderate intensity.

Cool down: this phase should be at least 5-10 minutes in which you reduce exercise intensity and return heart rate to resting levels. This phase may also consist of static stretching to improve flexibility and reduce muscle soreness.

Go Out and Play

Recreational and leisure activities, such as playing games and engaging in physical activity with friends or in a social environment, has lots of physical, mental and social benefits. Team and individual sports provide a chance to relax and engage socially, which has been shown to improve mood, reduce stress, improve sleep quality and boost self-confidence.

If going to the fitness centre does not appeal to you, there are a range of leisure activities in your community that you can become involved in. Check out the list below for some ideas:

Find a sport at your local sport and leisure centre:Play games with family or friends
  • Learn a racquet sport such as badminton, tennis or squash
  • Go for a swim or do aqua-aerobics
  • Take an exercise or Zumba dance class
  • Go ten pin bowling for a night out
  • Play boccia or bowls in the garden
  • Golf or pitch-and-putt
  • Try table tennis or even a kick about in the park
Join a club or sign up for weekly classesFor the bit more adventurous, try outdoor activities like:
  • Play team sports such as basketball or netball
  • Kick about with combat sports and martial arts
  • Try a dance class such as ballet, jazz or ballroom
  • Canoeing or archery
  • Rock climbing, backpacking or camping
  • Hiking or hill walking with a group
  • Fishing, horseback riding, or even cycling

Click here to find sports clubs and activities in your local area:

»
find activities in your local area
»
activities in the london area

If you are looking for a more challenging adventure, click here to learn about charity walks, marathons and cycling events in your area:

»
CHALLENGING ADVENTURES

Fun and Games

Having fun makes you feel good

Playing games and engaging in sporting activities either at home or within the local community can be lots of fun. Research has shown that when having fun while performing physical activity we are more likely to take part and stay motivated to engage in that activity. A few ways to make sport and games more fun is by playing music while playing, getting advice or lessons on the basics so that you can play at a higher level and to play with friends or family that will provide lots of support.

Importance of play

Research has shown that some of the side effects of mental illness include a decline in memory, attention, problem-solving skills and movement speed. Oftentimes, this leads to difficulty with social interaction with others. Playing sports and games, even board games or cards, are a fun way to engage with others and improve or maintain functional ability.

There are different types of games that have been shown to help improve social interaction, memory and attention. Playing sport, taking part in role playing games or enacting short stories allow for an opportunity to keep and make eye contact, talking and listening to each other, maintain body distance and give appropriate greetings. Board and card games help aid in developing memory and attention skills. Team activity challenges, adventure games and even computer games help by providing opportunities for problem-solving as well as maintaining attention.

Tai Chi (also called Tai Chi Chuan)

Tai Chi is a low impact, mind-body exercise that combines deep breathing and relaxation with slow, rhythmic movements. This activity is traditionally a form of martial arts, but is now more generally practiced as an exercise system, which is performed in a semi-squatting position at extremely slow speed. Tai Chi uses a sequence of standing exercises and postures that focus on specific movements, breathing and sound to build inner strength by emphasising mental strength and tranquillity of mind.

Research has shown that Tai Chi promotes relaxation that can reduce stress, anxiety, depression and mood disturbance. A strong component of Tai Chi is mindfulness, which is linked to many mental health benefits; however, intensive meditation is not recommended for individuals with psychosis. There are also great physical health benefits including increased muscular strength, flexibility and aerobic fitness.

Tai Chi is a conditioning exercise that is safe to practice every day. However, more intensive sessions should follow general exercise guidelines of not more than 2-4 times a week for 20-30 minutes. Local facilities offer Tai Chi as a group exercise class or can be performed at home (following a video or book). Once you learn the movements, you can perform the exercises wherever such as outdoors or anywhere you can find a quiet space.

Click here to find Tai Chi classes in your area:

»
TAICHIFINDER.CO.UK
»
TAOIST.ORG

Yoga

Research has demonstrated that there is a range of physical and mental health benefits to taking part in yoga on a regular basis. Yoga is a physical activity that focuses on strength, flexibility and breathing patterns using a series of movements or postures. Specific physical health benefits include increasing strength, flexibility and balance. Yoga has also shown to improve mood and reduce psychotic symptoms and depression.

There are different styles of yoga practice; examples include Hatha, Iyengar, Vinyasa and Ashtanga yoga. These different styles of practices are based on similar poses (or physical postures) and yoga breathing, with each of them having a different emphasis and exercise intensity. Regardless of which style you practice, yoga breathing is considered one of the most important components to improve mindfulness and decrease stress. Yoga breathing requires a person to inhale deeply through the nose and into the lungs. This alone, or in combination with various components of yoga practice provide physical and mental health benefits.

Previous research supports the role of yoga as an add-on therapy in schizophrenia to reduce negative symptoms and improve social interaction. A strong component of yoga is mindfulness or meditation, which is linked to many mental health benefits; however, intensive meditation may not be recommended for individuals with psychosis. Some clinical research has suggested that meditation may increase anxiousness in individuals experiencing serious mental illness. Be sure to discuss this with your clinician before beginning any form of meditation.

Click here to find yoga classes near you:

»
LOCALYOGACLASSES.CO.UK
»
YOGACLASSNEARYOU.CO.UK

References

American College of Sports Medicine (2013). ACSM’s Guidelines for exercise testing and prescription. Lippincott Williams & Wilkins.

American College of Sports Medicine (2014). ACSM’s Exercise management for persons with chronic diseases and disabilities. Lippincott, Williams & Wilkins.

Bangalore, N.G. and Varambally, S. (2012). Yoga therapy for Schizophrenia. International Journal of Yoga, 5(2), 85-91.

Bushe, C. J., Taylor, M., & Haukka, J. (2010). Review: Mortality in schizophrenia: a measurable clinical endpoint. Journal of Psychopharmacology, 24(4 suppl), 17-25.

Galletly, C. A., Foley, D. L., Waterreus, A., Watts, G. F., Castle, D. J., McGrath, J. J., … & Morgan, V. A. (2012). Cardiometabolic risk factors in people with psychotic disorders: the second Australian national survey of psychosis. Australian and New Zealand Journal of Psychiatry, 0004867412453089.

Ho, R.T.H, Yeung, F. Lo, P., Law, K.Y., Wong, K., Cheung, I. and Man Ng, S. (2012). Tai-Chi for residential patients with schizophrenia on movement coordination, negative symptoms, and functioning: A pilot randomized controlled trial. Evidence-Based Complementary and Alternative Medicine, Article ID 923925.

Kolotkin, R. L., Corey‐Lisle, P. K., Crosby, R. D., Swanson, J. M., Tuomari, A. V., L’Italien, G. J., & Mitchell, J. E. (2008). Impact of obesity on health‐related quality of life in schizophrenia and bipolar disorder. Obesity, 16(4), 749-754.

Lan, C., Wolf, S., Tsang, W.W. (2013). Tai Chi exercise in medicine and health promotion.

Evidence-Based Complementary and Alternative Medicine, Article ID 298768.

Richardson, C. R., Faulkner, G., McDevitt, J., Skrinar, G. S., Hutchinson, D. S., & Piette, J. D. (2005). Integrating physical activity into mental health services for persons with serious mental illness. Psychiatric Services, 56(3), 324-331.

Saha, S., Chant, D., & McGrath, J. (2007). A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time?. Archives of General Psychiatry, 64(10), 1123-1131.

Strassnig, M., Brar, J. S., & Ganguli, R. (2003). Body mass index and quality of life in community-dwelling patients with schizophrenia. Schizophrenia Research, 62(1), 73-76.

Strassnig, M., & Ganguli, R. (2007). Weight loss interventions for patients with schizophrenia. Clinical Schizophrenia & Related Psychoses, 1(1), 43-53